Antibiotic Selection for Foreign Body Removal from the Hand
For foreign body removal from the hand, use cefazolin 2g IV as first-line prophylaxis; if the patient has a cephalosporin allergy, use clindamycin 900 mg IV as the alternative. 1
Primary Recommendation
Cefazolin 2g IV slow infusion is the standard prophylactic antibiotic for soft tissue procedures involving foreign material or contaminated wounds of the hand, limited to the operative period (maximum 24 hours). 1
If the procedure duration exceeds 4 hours, re-inject 1g of cefazolin to maintain adequate tissue levels. 1
The target bacteria for hand wounds include staphylococci (S. aureus), streptococci, and potential gram-negative organisms from soil contamination. 1
Alternative for Cephalosporin Allergy
If the patient has a documented allergy to cephalosporins (cefazolin, cephalexin), the recommended alternative is clindamycin 900 mg IV slow infusion as a single dose. 1
Understanding the Allergy Context
For patients with immediate-type cephalosporin allergy (urticaria, anaphylaxis occurring within 1-6 hours), avoid all cephalosporins with similar R1 side chains. 1, 2
Cephalexin shares identical R1 side chains with amoxicillin and ampicillin, so these penicillins should also be avoided if cephalexin allergy is documented. 1, 2
For delayed-type non-severe reactions (maculopapular rash after 1 hour), cephalosporins with dissimilar side chains may be considered, but clindamycin remains the safer choice for prophylaxis. 1, 2
Additional Considerations for Contaminated Wounds
For highly contaminated soft tissue wounds with soil, debris, or crush injury, the guideline recommends cefamandole 1.5g IV or cefuroxime 1.5g IV with re-injection of 0.75g if duration exceeds 2 hours. 1
In cases of severe contamination or articular involvement, consider adding gentamicin 5 mg/kg/day to clindamycin if beta-lactams are contraindicated, with treatment limited to 48 hours maximum. 1
Duration of Prophylaxis
Antibiotic prophylaxis should be limited to the operative period only, with a maximum duration of 24 hours post-procedure. 1
Extended prophylaxis beyond 24 hours is not supported by guidelines and increases resistance risk without improving outcomes. 1
Common Pitfalls to Avoid
Do not use vancomycin as routine prophylaxis unless there is documented MRSA colonization, previous antibiotic therapy, or true anaphylactic reaction to both beta-lactams and clindamycin. 1
Vancomycin requires 120-minute infusion and must be completed at the latest by the start of the procedure (ideally 30 minutes before incision). 1
Avoid prescribing oral antibiotics like cephalexin for prophylaxis in the operating room setting—IV administration ensures adequate tissue levels at the time of incision. 1